Guillain-Barré syndrome: perspectives with infants and children

A Rare Case of Guillain–Barré Syndrome with Signs of Meningeal Irritation and Treatment-Related Fluctuations/Relapse

Guillain–Barré Syndrome is an acute inflammatory demyelinating polyradiculoneuropathy that can present at any age. The presentation of Guillain–Barré syndrome may be variable as the classic symptoms of areflexia and flaccid paralysis may or may not be present. Here we reported a case of a 15-year-old male patient who presented with complaints of weakness in bilateral lower limbs with inability to sit along with slurred speech and drooling of saliva with positive meningeal signs like neck stiffness and Kernig's sign. His symptoms improved with immunoglobulin therapy. Five days later, the child again had pain and increased weakness with increased work of breathing for which repeat dose and course of immunoglobulins were given. As patients with signs of meningeal irritation may suggest other diseases such as meningitis, it is important to consider atypical cases of Guillain–Barré syndrome along with treatment-related fluctuations as observed in our patient.

A Case Report of Guillain-Barre Syndrome in an Eleven-Month Infant

Guillain-Barre syndrome (GBS) is an acute immune-mediated progressive predominantly motor symmetric polyradiculoneuropathy which causes demyelination and leads to weakness, ataxia and areflexia. There are a variety of forms of the syndrome; and despite being the most common cause of acute flaccid paralysis in children, it has a low incidence under 18 years old, and it is even rarer in children less than 2 years of age. Very few cases have been reported under 12 months of age. We describe a case of an 11-month-old male infant presenting with weakness and inability to ambulate who was diagnosed with GBS.

Clinical and serological prognostic factors in childhood Guillain-Barré syndrome: A prospective cohort study in Bangladesh

Guillain-Barré syndrome (GBS) is the most common cause of acute flaccid paralysis in children. The objective of this study was to investigate the preceding infections, clinical, serological and electrophysiological characteristics and outcome of childhood GBS in Bangladesh. We included 174 patients with GBS aged <18 years from a prospective cohort in Bangladesh between 2010 and 2018. We performed multivariate logistic regression to determine the risk factors for poor outcome. Among 174 children with GBS, 74% (n = 129) were male. Around half of the patients (49%, n = 86) had severe muscle weakness, 65% (n = 113) were bedbound (GBS disability score 4) and 17% (n = 29) patients required mechanical ventilation at admission. Campylobacter jejuni serology and anti-GM1 IgG antibody were positive in 66% and 21% of the patients respectively. One hundred and forty-three (82%) patients did not receive standard treatment and half of them recovered fully or with minor deficits at 6-month. Twenty patients (11%) died throughout the study period. At 3-month of onset of weakness, complete recovery or recovery with minor deficit was significantly higher in demyelinating GBS patients compared to axonal GBS patients (86% vs 51%, P = .001). Cranial nerve palsy (OR = 4.00, 95%CI = 1.55-10.30, P = .004) and severe muscle weakness (OR = 0.16, 95%CI = 0.06-0.45, P = .001) were the important risk factors of poor outcome in children with GBS. Further large-scale studies are required for better understanding of factors associated with mortality and morbidity in childhood GBS.

Therapeutic Plasma Exchange in Guillain-Barre Syndrome and chronic inflammatory demyelinating polyradiculoneuropathy

Therapeutic plasma exchange (TPE) has been used as a treatment modality in many autoimmune disorders, including neurological conditions, such as Guillain-Barre syndrome (GBS) and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). The American Society for Apheresis (ASFA) publishes its guidelines on the use of therapeutic apheresis every 3 years based on published evidence to assist physicians with both the medical and technical aspects of apheresis consults. The ASFA Guidelines included the use of TPE in both GBS and CIDP as an acceptable first-line therapy, either alone and/or in conjunction with other therapeutic modalities. In this article, we briefly reviewed GBS and CIDP, discussed the role of apheresis in these conditions as well as various technical aspects of the TPE procedure, such as apheresis calculation, number of volume exchange, replacement fluid, and management of potential complications.

New Cluster of Acute Flaccid Myelitis in Western Pennsylvania

Acute flaccid myelitis is a debilitating illness characterized by acute onset of limb weakness, with one or more spinal segments displaying magnetic resonance imaging-confirmed gray matter lesions. Since the first outbreak in 2014, tracking by the Centers for Disease Control and Prevention has demonstrated biennial epidemics in the United States, with a current outbreak occurring in 2018. The cases of 3 children with acute flaccid myelitis who were initially thought to have common nonneurologic diagnoses are presented. Emergency physicians need to be vigilant to recognize the subtleties of acute flaccid myelitis because the illness progression is rapid and therapy is nuanced.

Acute combined central and peripheral nervous system demyelination: a case report

Guillain-Barré syndrome (GBS) and acute disseminated encephalomyelitis (ADEM) are demyelinating neurologic disorders with different target organs. Although they share similar pathogenetic mechanism, reports of simultaneous occurrence of the 2 disorders are rare. A 2 year 6 month old girl visited our hospital for fever, cough, and general weakness. Although the muscle power of extremities showed mild weakness and voiding difficulty, initial deep tendon reflex of both knees and ankles was normal. A nerve conduction study to evaluate the weakness revealed the absence of F waves. Cerebrospinal fluid analysis demonstrated pleocytosis with lymphocyte predominance and elevated protein levels. Magnetic resonance imaging showed abnormal T2 hyperintensity in pons, medulla and spinal cord. Serum anti-GD1b antibody was positive. Based on clinical findings, laboratory findings, nerve conduction study, and neuroimaging, the diagnosis of GBS and ADEM was made. This is the first case of GBS accompanied by ADEM in Korea.

Miller Fisher syndrome

A man aged 30 years presented to the emergency department (ED) with ataxia, areflexia, facial weakness, ophthalmoplegia, extremity weakness and back pain for 4 days. 4 days prior to attending the ED, the patient had suffered from diarrhoea for 2 weeks. The diagnosis of Miller Fisher syndrome was performed on the dual basis of clinical features in addition to an investigations report. Nerve conduction studies and anti-GQ1b IgG antibody analysis were requested. Once IgA deficiency was ruled out, the patient was started on intravenous immunoglobulin (400 mg/kg/day).

A New Observation of an Atypical and Severe Variant of the Guillain-Barre Syndrome in a Child: Remaining Challenges for Diagnosis, Nosologic Classification, and Therapeutic Course

Guillain-Barré syndrome is a rare acute polyradiculoneuropathy. Several variants and unusual presentations have been described, particularly in pediatrics. In most cases, making an early diagnosis is challenging due to the treatments that consist in the rapid administration of intravenous immunoglobulin or plasma exchange. The authors present the case of a 7-year-old boy with an atypical and severe axonal Guillain-Barré syndrome, associated with Mycoplasma pneumonia. When he was admitted, febrile respiratory failure was the main focus, and then he presented signs of acute polyneuropathy with cranial nerve palsy and brief hyperreflexia. Mechanical ventilation was required for 48 days as well as 2 cycles of intravenous immunoglobulin. The authors describe all the medical challenges that the authors encountered. This case highlights the fact that respiratory distress can be the main clinical symptom in children. This delays the establishment of a correct diagnosis, even more so when neurological manifestations are abundant and unusual.

Investigation of suspected Guillain-Barre syndrome in childhood: what is the role for gadolinium enhanced magnetic resonance imaging of the spine?

AIM

To review the role of gadolinium-enhanced magnetic resonance imaging of the spine in the diagnosis of paediatric Guillain-Barre syndrome and compare it with nerve conduction studies and cerebrospinal fluid analysis.

METHODS

A retrospective review of investigations undertaken in children admitted to our institution with acute Guillain-Barre syndrome over a 10-year period was performed.

RESULTS

Seven of eight children (88%) displayed post-gadolinium nerve root enhancement consistent with Guillain-Barre syndrome. This compared with supportive nerve conduction studies in 21/24 children (88%) and cerebrospinal fluid protein analysis consistent with the diagnosis in 16/20 children (80%).

CONCLUSION

Nerve conduction studies are the recognised 'gold standard' technique for confirming a clinical diagnosis of Guillain-Barre syndrome. In this study, a high positive rate was demonstrated. While more experience is necessary, this study and the literature support gadolinium enhanced magnetic resonance imaging of the spine as a valuable, although not necessarily superior, investigation in the diagnosis of Guillain-Barre syndrome. It may be of particular benefit when specialist neurophysiology expertise is unavailable.

Guillain-Barré syndrome

• Based on strong research evidence, in countries where poliomyelitis has been eliminated, GBS is the most common cause of acquired paralysis in children. (9) • Based on strong research evidence, GBS describes a spectrum of disorders caused by an autoimmune reaction against peripheral nerve components, including the myelin sheath and the axon. (10)(11) • Based on strong research evidence, GBS usually is preceded by a bacterial or viral infection, less likely by vaccination in the 1 to 4 weeks before onset. The strongest relationship is with infection by C jejuni. (12)(13) • Based on strong research evidence, GBS in children most often presents with symmetrical ascending paralysis, diminished or absent reflexes, and often severe pain. Pain may lead to a delay in diagnosis. (2) (3)(9)(14) • Based on strong research evidence, the progressive phase peaks in 7 to 14 days and can lead to various levels of weakness, from abnormal gait to total paralysis, cranial nerve weakness, pain, respiratory compromise, and autonomic instability. (2) • Based on some research evidence and consensus, children require hospitalization and often intensive care until their condition stabilizes because of significant risk of respiratory compromise and autonomic instability. (15) • Based on strong research evidence in adults and some research evidence in children, IVIG and plasma exchange hasten recovery from GBS in patients with impaired ability to ambulate. (4)(6) • Based primarily on consensus, IVIG is the treatment of choice in children with GBS. (6)(9)(15) • Based on strong research evidence, the prognosis for full functional recovery in childhood GBS is excellent. (2)(8)(9).

Miller-Fisher syndrome in association with enterovirus infection

Miller-Fisher is a rare syndrome of childhood that presents with external ophthalmoplegia, ataxia, and areflexia. It has been mainly associated with a preceding Campylobacter infection and less commonly with other bacterial or viral infections. This report describes, for the first time, a child with Miller-Fisher syndrome and documented Enterovirus infection, as it was proven by the isolation of Enterovirus from cerebrospinal fluid by polymerase chain reaction testing.

Acute motor-sensory axonal Guillain-Barré syndrome with unilateral facial nerve paralysis after rotavirus gastroenteritis in a 2-year-old boy

Guillain-Barré syndrome (GBS) is well known as presenting with acute immune-mediated polyneuropathies, with strong associations with antecedent infections. Several variant forms of GBS have been described, including acute inflammatory demyelinating polyneuropathy, acute motor axonal neuropathy, acute motor-sensory axonal neuropathy, and sensory GBS. We present a rare case of 2-year-old boy with acute motor and sensory polyneuropathy and left-sided facial nerve paralysis after rotavirus infection. He received immunoglobulin i.v. with subsequent satisfactory recovery.

Miller Fisher syndrome in a toddler with influenza A (pH1N1) infection

A 17-month-old previously healthy child presented with a 2-day history of inability to fully open his eyes and slight gait ataxia. In the month preceding admission, he had had low grade, intermittent fevers, followed by a nonproductive cough and sneezing. During hospital admission he lost deep tendon reflexes and was unable to walk. Lumbar puncture revealed abnormally high protein, and a nasopharyngeal specimen was positive for influenza A (pH1N1). He received intravenous immunoglobulin and oseltamivir with clinical improvement. Although it is difficult to ascertain whether pH1N1 or another microorganism was responsible for this toddler's neurologic syndrome, this is the first reported case of Miller Fisher syndrome associated with pH1N1. During pandemics, one may expect to see an increased incidence of uncommon neurologic complications of influenza.

Acquired facial palsy with hypertension secondary to Guillain-Barre syndrome

Most cases of facial nerve paresis are idiopathic (Bell's palsy). However, rare and potentially dangerous conditions may present in this manner. We report 2 children presenting with unilateral lower motor neuron facial nerve palsy and hypertension. A diagnosis of Guillain-Barre syndrome was made in both; literature linking facial nerve palsy in childhood with hypertension and Guillain-Barre syndrome is reviewed.

Overview of paediatric neuromuscular disorders and related pulmonary issues: diagnostic and therapeutic considerations

Pulmonary compromise is common in neuromuscular disease. Respiratory failure may be a presenting feature of neuromuscular disease and remains a major cause of morbidity and mortality. This article will review the current understanding of the more commonly encountered neuromuscular disorders in childhood and emphasize related pulmonary issues.

Cardiovascular complications of the Guillain-Barré syndrome

The Guillain-Barré syndrome (GBS) is the most common cause of acute flaccid paralysis in young adults and the elderly and an important cause of admission to intensive care units. Manifestations of the GBS vary from monoparesis to life-threatening paralysis of the respiratory muscles. The latter is often punctuated by the presence of cardiac involvement. This ranges from variations in blood pressure to involvement of the myocardium and potentially fatal arrhythmias. This review addresses some of the common cardiovascular complications of the GBS, with their myriad presentations and therapeutic options, as well as potential preventive measures that can be helpful in the management of patients admitted to intensive care units. In conclusion, it is necessary to recognize the potentially fatal cardiovascular complications associated with the GBS and treat them accordingly.

Outcome of axonal and demyelinating forms of Guillain-Barré syndrome in children

Previous reports have suggested that outcome is worse in the axonal compared with the demyelinating form of Guillain-Barré syndrome (GBS). We performed a retrospective study of 23 children with electrophysiologically confirmed cases of predominant subtypes of GBS to investigate this issue. The patients were classified based on the electrodiagnostic features: Ten (44%) had acute inflammatory demyelinating polyradiculoneuropathy, eight (35%) had acute motor axonal neuropathy, and five (21%) had acute motor-sensory axonal neuropathy. All patients received a standard intravenous immunoglobulin therapy (0.4 g /kg /day for 5 consecutive days). In the acute phase of the disease, patients with the axonal forms of GBS were more disabled than were those with the demyelinating GBS, as measured by GBS scores. Mechanical ventilation was required in five (38%) patients in the axonal group compared with one (10%) patient in the demyelinating group. There was no significant difference at 6 months in GBS scores between demyelinating and axonal forms of GBS. All 20 survivors recovered completely by 12 months. After standard intravenous immunoglobulin therapy, children with axonal forms of GBS recover more slowly than those with the demyelinating form, but outcome at 12 months appears to be equally favorable in two groups.

A child with Miller Fisher syndrome

We describe the case of a six-year-old girl who presented with a 3-day history of diplopia and gait disturbance following a febrile flu-like illness. On examination she was found to have ataxia, areflexia and ophthalmoplegia, and a diagnosis of Miller Fisher syndrome was made after the exclusion of other conditions. This report outlines the frequency of Miller Fisher syndrome and lists the differential diagnoses that should be considered in Australia. In addition, the occurrence of pupillary dysfunction is discussed.